CHURCHWIDE HEALTHCARE - Pension Fund

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Highmark BCBS Medical Program About your Churchwide Healthcare coverage Welcome to Churchwide Healthcare (CWHC) coverage through Christian Church Healthcare Benefit Trust (CCHCBT). CCHCBT has contracted with Highmark BCBS to act as Third-Party Administrator of the benefits program, which gives you access to the BCBS system, one of the most widely recognized and accepted throughout the United States. For decades, the nationwide BCBS family of independent plan providers has offered members innovative health coverage designed to meet their needs. You will be covered through the CWHC PPO plan administered by Highmark BCBS. No matter where you live in the United States, you may take advantage of the expansive provider networks and discounts arranged by the PPO plans around the country. In most cases, you should not have to file claim forms or pay anything except your co-payments, deductibles, etc., in advance. This guide explains your coverage through CWHC and the PPO program. For more information, such as details about how we cover a particular service or prescription drug, please read your contract or use one of the sources located in the front of this guide. How does my medical plan work? You pay less out-of-pocket if you use the physicians, hospitals, and other health care providers that participate in the BCBS PPO network. While you don’t need referrals to visit specialists, you receive the highest level of benefits when you use Preferred Providers. In some instances, such as hospital admissions and home healthcare services, Highmark BCBS can require prior approval. In other words, Highmark BCBS must approve the need for the care before you seek it, or they may choose not to pay for such care. To find preferred providers (in-network): Visit the www.highmarkbcbs.com web site and click on “Find a Physician or Facility.” Call 1-800-648-4078 to find out if the provider you select is Preferred. (Remember, you will reach your out-of-pocket maximum quicker when you use Out-of-Network Providers. Further, there are separate deductibles and out of pocket limits for Out-of-Network medical services.) The medical summary of benefits in the booklet shows a comparison between benefits when you use In-Network Providers and benefits when you use Out-of-Network Providers. Also, keep in mind that your health plan pays the Allowed Price for services and supplies. In-Network Providers agree to accept the Allowed Price as payment in full. When you use Out-of-Network Providers, you must pay the difference between the Allowed Price and the provider’s charge. Benefits for most services require that you pay a deductible each year for In-Network Providers’ services and Out-of-Network Providers’ services. Once you have met your deductible, you share the cost of your care through coinsurance. Deductible and out-of-pocket amounts do not cross apply. Once again, your coinsurance percentage amount for Out-of- Network Providers is higher than the one for In-Network Providers. You need only pay the deductible and coinsurance until you meet your out-of-pocket maximum for the year. PAGE 4
Summary of Medical Benefits Benefit Category PPO Medical Plan Benefit Summaries In-Network PPO1 PPO2 PPO HDHP Benefit Period Calendar Year Calendar Year Calendar Year Deductible: Individual $500 $1,000 $2,500 Deductible: Family $1,500 $3,000 $5,000 Payment Level/Coinsurance 80% after deductible until out-of-pocket is met, then 100% Out-of-Pocket (OOP) Maximums: Individual $3,000 $4,500 $6,050 Out-of-Pocket (OOP) Maximums: Family $6,000 $9,000 $12,100 Deductible included in OOP Maximum No No No Lifetime Maximum Unlimited Physician & Specialist Office Visits 80% after deductible Adult Preventive Care - Routine physical exams 100%; deductible does not apply Adult Preventive Care - Routine gynecological exams including a Pap Test Adult Preventive Care - Mammograms, as required Pediatric Preventive Care - Routine physical exams Pediatric Preventive Care - Immunizations Emergency Room Services Ambulance Hospital Expenses - Inpatient Hospital Expenses - Outpatient Hospital Expenses - Maternity Infertility Counseling, Testing & Treatment Medical/Surgical Expenses (Except Office Visits) Spinal Manipulations Diagnostic Services (Lab, X-Ray & other tests) Physical Medicine (Acupuncture included) Occupational/Speech Therapy Durable Medical Equipment, Orthotics and Prosthetics Skilled Nursing Facility Care Home Healthcare Private Duty Nursing Hospice Mental Health/Substance Abuse - Impatient Mental Health/Substance Abuse - Outpatient Precertification Requirements 100%; deductible does not apply 100%; deductible does not apply 100%; deductible does not apply 100%; deductible does not apply 80% after $100 copayment & deductible; 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible Combined Limit: 20 visits per calendar year 80% after deductible 80% after deductible Combined Limit: 20 visits per calendar year 80% after deductible Combined Limit: 20 visits per calendar year 80% after deductible 80% after deductible Combined Limit: 120 visits per calendar year 80% after deductible Combined Limit: 40 visits per calendar year 80% after deductible 80% after deductible Combined Limit: 180 days per lifetime 80% after deductible Combined Limit: 30 days/calendar year 80% after deductible Combined Limit: 30 visits/calendar year Performed by member* PAGE 5
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CHURCHWIDE HEALTHCARE - Pension Fund

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